"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

December 31, 2018

Just out of curiosity, I've checked what I'd been blogging about here on December 31, 2008...ten short years ago.

It was mostly bird flu; the H1N1 "swine flu" pandemic was almost six months in the future, and I hadn't yet realized that bird flu could not be considered apart from an enormous range of global-health issue. (Also in the future: Haiti's cholera, MERS, H7N9, Zika, and urban Ebola.)

So I was reporting on a two-month-old baby in Shenzhen who was recovering from H9N2. The case provoked authorities in Guangdong to tighten inspection of poultry markets.

Indian doctors in Manipur were working "round the clock" to prevent the spread of H5N1 to their city after an outbreak in Assam state.

In Nigeria, the Bauchi state ministry of health was on the alert for H5N1 as well; it was about that time, I seem to recall, that Nigeria had one human case of H5N1, which had been fatal.

Here in Canada, Ontario was finally making public the rates of hospital-acquired infections from superbugs like C. diff and MRSA.

On New Year's Day, I was reporting a health scare about possible H5N1 in an Indonesian village. And I posted links to the old Flu Wiki Forum (no longer online) and Mike Coston at Avian Flu Diary (still very much online).

Ten years later we're watching a slightly different mix of bacteria and viruses, but the war goes on. It has been my good fortune to follow the war from a safe vantage point, while gaining ever deeper respect for the men and women fighting it from the villages of Asia and Africa and Latin America to the hospitals of Europe and North America. I hope my posts have accurately reported their extraordinary efforts.

PATNA: The Indian Veterinary Research Institute (IVRI) team from Uttar Pradesh has directed the Patna zoo authorities to keep people away from the premises as the avian flu (H5N1 virus) has killed eight birds there so far since December 16.

IVRI experts Dr S Nandi and Dr Karikalan M, who reached Patna on Saturday, gave a PowerPoint presentation on Sunday to the zoo officials and the team members of chief wildlife warden regarding H5N1 virus (avian influenza) and precautionary measures to be taken.

Zoo director Amit Kumar said the IVRI experts instructed the zoo staff to take all precautions before entering the premises. "Staff members should not use the same mask twice. In fact, they are not even bringing their bicycles inside," said Kumar and added that there was no need to panic.

Six peafowls died last week due to bird flu last week. Another peafowl and a khalij pheasant died on Saturday.

The epidemiological situation of the Ebola Virus Disease dated December 30, 2018:

• Since the beginning of the epidemic, the cumulative number of cases is 598, 550 confirmed and 48 probable. In total, there were 363 deaths (315 confirmed and 48 probable) and 204 people healed.

• 47 suspected cases under investigation.

• 2 new confirmed cases, including 1 in Komanda and 1 in Mabalako.

• 2 new deaths of confirmed cases (all community deaths), 1 in Mabalako and 1 in Komanda.

/! \ The data presented in this table is subject to further changes after thorough investigation and after redistribution of cases and deaths in their health areas.

News of the response

Vaccination

• Interruption of immunization in Goma, Beni, Butembo, Katwa, Komanda and Mabalako following protests by the population.

• Since vaccination began on 8 August 2018, 53,737 people have been vaccinated , including 19,363 in Beni, 10,761 in Katwa, 5,875 in Butembo, 5,377 in Mabalako, 2,258 in Kalunguta, 1,663 in Mandima, 1,297 in Komanda, 1,009 in Oicha, 942 in Goma, 791 in Vuhovi, 750 in Masereka, 700 in Lubero, 659 in Kyondo, 599 in Mutwanga, 434 in Bunia, 394 in Musienene, 355 in Tchomia, 167 in Nyankunde, 137 in Karisimbi, 70 in Biena, 63 in Alimbongo, and 13 in Kisangani.

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018.

Access to the internet and social networks was cut "on instruction of the government" in the Democratic Republic of Congo Monday, December 31 after the general elections, said operators to AFP.

"Dear client, at the instruction of the government, our Internet services are suspended for an indefinite period," said the Global Provider in an SMS received by AFP.

"It is the government that cut," said a representative of the mobile phone operator Vodacom AFP who was surprised by problems of Internet access in Kinshasa.

Access to data on the Airtel and Vodacom networks is cut off, the AFP team in Goma and Beni, in North Kivu (East), also found 2,000 km from the capital.

Access to the Whatsapp network was also impossible in Lubumbashi (south) on Vodacom.

At the beginning of the morning already, disturbances and intermittent cuts were observed by the users of several networks before the complete cut occurred around noon in particular in Kinshasa, the capital of the DRC.

Vodacom and Airtel are the main mobile networks in the DRC with Frenchman Orange.

"I'm sorry to learn just before entering the room that we cut the Internet," the secretary general of the Bishops' Conference (Cenco) told the press, reporting on the results of the meeting. the electoral observation mission of the Catholic Church.

In his initial statement, Father Donatien Nshole congratulated "the government for ensuring the smooth operation of the internet and SMS" on Sunday during the voting day.

The SMS exchanges were still working on Monday morning, AFP reported in Kinshasa on the Airtel and Vodacom networks.

"We will start the filtering of internet access", had told AFP early this morning a source who does not want to be quoted, stating that it was "to block the images and videos on the networks social."

The cut came as polling station results were broadcast on, among others, Twitter and WhatsApp. The CENI plans to publish the provisional results of the elections on Sunday January 6th.

This is a very discouraging development, and it seems likely to result in yet more civil violence in many parts of the DRC. That in turn will disrupt the response to Ebola and push some people in the hot zone either into remote villages under Mai-Mai or ADF control, or right across the border into Uganda or Rwanda or South Sudan.

If I were the minister of health in any of those countries, I would order the redoubling of training and preparation for the appearance of Ebola.

Doctors in Gaza and the West Bank have said they are battling an epidemic of antibiotic-resistant superbugs, a growing problem in the world’s conflict zones, which could also spill over the Palestinian borders.

The rise and spread of such virulent infections adds to the devastation of war, increasing medical costs, blocking hospital beds because patients need care for longer, and often leaving people whose injuries might once have been healed with life-changing disabilities.

Gaza is a particularly fertile breeding ground for superbugs because its health system has been worn down by years of blockade, and antibiotics are in short supply, the Bureau of Investigative Journalism has found.

“This is a global health security issue because multi-drug-resistant organisms don’t know any boundaries,” said Dina Nasser, lead infection control nurse at Augusta Victoria hospital in East Jerusalem, who has also worked in Gaza. “That’s why the global community, even if it’s not interested in the politics of Gaza, should be interested in this.”

Even though doctors in Gaza knew protocols to prevent the rise of drug-resistant bacteria, persistent shortages of antibiotics meant they could not always follow them, they told reporters. Patients take incomplete courses of antibiotics or are prescribed a mix because the right medicine is not available.

Shortages of water, power and fuel for generators mean doctors cannot always meet even basic hygiene standards, making it easier for any drug-resistant infection to spread. At times doctors are not even able to wash their hands and there are shortages of gloves, gowns and chlorine tablets for disinfecting.

A decade-long Israeli blockade on travel and trade means Gaza is relatively isolated compared with other conflict areas that have proved fertile ground for superbugs.

The US military noted the spread of drug-resistant bacteria from Iraq more than a decade ago; it logged such a huge rise in injured personnel returning with resistant Acinetobacter that the bacteria were eventually nicknamed “Iraqibacter”.

But Gaza is not totally cut off. Small numbers of patients do transfer to other hospitals in Palestine, Israel and nearby countries such as Jordan, Egypt and Lebanon.

Healthy people can carry the bacteria without showing any symptoms, so doctors and aid workers travelling in and out of Gaza could transport superbugs to other countries. The bacteria can also travel without human hosts.

“It will always get out,” said Dr Ghassan Abu Sittah, who studies conflict medicine at the American University of Beirut Medical Center (AUBMC). “The untreated sewage from Gaza containing multi-drug-resistant bacteria goes into the aquifer and that is a shared aquifer [with Egypt and Israel].

“There are papers from Scotland that show actually multi-drug-resistant bacteria can be found in the pellets of migrating birds. The idea anyone could be immune to this phenomenon is absurd.”

The scale of the problem was thrown into relief by an increase in violence in Gaza this year, when more than 200 people were killed and thousands injured, mostly shot in the legs, during protests along the border that culminated in a “Great March of Return” rally in May.

Dr Mahmoud Mattar, an orthopaedic surgeon, said around 2,000 Gazans were currently dealing with serious gunshot injuries to the legs that would typically require multiple reconstruction operations and two years of rehabilitation.

Nearly all of these patients have also contracted superbug infections, meaning surgeons have to delay closing their wounds. That reduces the chances of successful reconstruction, extends hospital stays and increases the risk of amputation.

Eliminated from the elections of December 30 by the CENI, the people of Beni organized themselves to vote "manually" until late in the evening. At least five voting centers have been created because of a center in each of the four municipalities that Beni has.

In Kasabinyole neighborhood in Ruwenzori commune, which was abandoned by three-thirds of its population following repeated incursions by ADF (Allied Democratic Forces) rebels, hundreds of people invaded the "polling stations" at the Munzenda primary school.

"We residents of Ruwenzori commune are relieved by this vote we just had here, I was in hospital bed but when I learned that we had just installed a polling station here at the Anglican church, I got up straight to vote despite Ebola and insecurity, we were waiting with open arms for this election, it's our right being Congolese and we can not be deprived of it. ... We give thanks to God for this favor granted us," said Ornelie Kaswera, a resident of the city.

The paper vote in which thousands of inhabitants of Beni took part took place without any incident on the whole city. In some "polling stations", the "electoral agents" took the temperature of each voter before the vote; the washing of hands was mandatory to protect against the Ebola virus disease that has been living in the region since last August.

Kikumu Kamabu, a senior citizen, who also took part in the vote, said he sent a message to the president of the CENI who postponed the elections to March 2019 in Beni following Ebola and insecurity.

"We came to vote because of the suffering we are going through, we are being killed like animals, I had already fled from Beni because of the killings but when I learned that on December 30 there will be a vote in the country, I went back to my entity where I was enlisted to vote. All that the president of the CENI said about the postponement of elections in Beni, that's his business, I do not have any problem with the CENI but I want Kinshasa to know that there was a vote in Beni without any incident," he said.

At 6 pm, the manual voting was still going on in Beni before beginning the counting. According to the "organizers", the results will be published Tuesday in the afternoon before being sent to the Monusco and CENI.

The epidemiological situation of the Ebola Virus Disease dated December 29, 2018:

• Since the beginning of the epidemic, the cumulative number of cases is 596, of which 548 are confirmed and 48 are probable. In total, there were 361 deaths (313 confirmed and 48 probable) and 204 people healed.

• 8 suspected cases under investigation.

• 3 new confirmed cases, 2 in Butembo and 1 in Oicha.

• 1 new case death confirmed in Oicha (community death).

• 1 new person healed out of Butembo CTE.

General slowdown of response activities due to security situation.

/! \ The data presented in this table is subject to further changes after thorough investigation and after redistribution of cases and deaths in their health areas.

News of the response

Vaccination

• Interruption of immunization in Goma, Beni, Butembo, Katwa, Komanda and Mabalako following protests by the population.

• Since vaccination began on 8 August 2018, 53,737 people have been vaccinated , including 19,363 in Beni, 10,761 in Katwa, 5,875 in Butembo, 5,377 in Mabalako, 2,258 in Kalunguta, 1,663 in Mandima, 1,297 in Komanda, 1,009 in Oicha, 942 in Goma, 791 in Vuhovi, 750 in Masereka, 700 in Lubero, 659 in Kyondo, 599 in Mutwanga, 434 in Bunia, 394 in Musienene, 355 in Tchomia, 167 in Nyankunde, 137 in Karisimbi, 70 in Biena, 63 in Alimbongo, and 13 in Kisangani.

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018.

Three opposition strongholds will see no casting of ballots at all after the authorities cancelled the vote there, citing health risks from an ongoing Ebola outbreak and ethnic violence.

Some polling places in other opposition bastions in the capital Kinshasa did not open until more than seven hours after the 6 a.m. (0500 GMT) start because voter rolls had not arrived.

Elections are a rare event in Congo, which has been plagued by authoritarian rule, assassinations, coups and civil wars since independence from Belgium in 1960.

If President Joseph Kabila, in power since his father's assassination in 2001, steps down after the vote it will be the country's first ever democratic transition.

Kabila voted early in the morning in Kinshasa at the same school as the candidate he is backing, former interior minister Emmanuel Ramazani Shadary, whom the latest opinion polls showed trailing two opposition candidates.

"My only concern is that we have this very heavy rain and probably voter turnout might be low, but hopefully the skies will clear, and the voters will turn out in numbers," Kabila, wearing a dark blue suit, told reporters.

The Catholic bishops conference (CENCO) said electronic voting machines, criticised by the opposition as vulnerable to fraud, had dysfunctioned in at least 544 of 12,300 polling places it monitored. It also said 846 polling stations were installed in "prohibited places" like military and police posts.

Some voters also complained they could not find their names on the rolls, and flooded streets in Kinshasa prevented others from reaching their polling stations.

My concern about the election is the effect it may have on the response to the Ebola outbreak. I gather that some voters in North Kivu are casting ballots regardless of the "postponement" of the election there, and protests have already shut down contact tracing and vaccination for days.

Whoever wins the election (better said, whoever is declared the winner) will lack legitimacy, and may have serious trouble establishing effective authority in Kinshasa, never mind North Kivu and Ituri. We may well see Oly Ilunga replaced as minister of health, and even if he stays in office his credibility in the Ebola zone could be seriously weakened.

Continued unrest in cities like Beni is likely after the election, which will further hamper the response and make it difficult to sustain case finding and vaccination—perhaps even to provide Ebola treatment centres with adequate equipment, medications, and food.

Political violence could also drive more people out of their communities and into cities only a little less turbulent—or right across the border into Rwanda or Uganda.

All these possibilities make the containment of Ebola less likely. If it gets out of the present hot zone, perhaps all the way to Kinshasa or Kampala, 2019 could become a disaster that would dwarf 2014-2016 in East Africa.

As the general doctors’ strike in various states of Sudan has entered its seventh day, the strike action has spread to at least 38 hospitals in Sudan.

The doctors have downed tools in solidarity with the mass public protests in the country. During the strike, they are treating emergency cases only, while many doctors have answered the call to assist civilians injured by government forces suppressing the gatherings.

Doctors detained

The Sudanese Central Doctors’ Committee pointed in a statement to the detention of a number of doctors in El Gedaref in eastern Sudan. They were threatened and beaten before they were released again.

On Thursday, doctors and medical students of the Faculty of Medicine in El Gedaref held a protest in front of the El Gedaref Teaching Hospital in solidarity with the march organised by the Sudan Professionals Association in Khartoum on Tuesday, which demanded the step-down of President Omar Al Bashir and overthrow of the regime.

In their latest statement, the doctors deplored the deaths of dozens of civilians who were shot dead by the Sudanese security forces. They hailed the steadfastness of doctors and their response to the call of the street in demanding freedom and a decent life.

Pharmacists

The Sudanese Central Pharmacists Committee, in cooperation with the Community Pharmacists Committee and the Department of Pharmacy Owners announced a general strike and closure of all pharmacies in Khartoum state last week, in solidarity with the doctors and mass protests.

The pharmacists said in a statement that work will continue in emergency pharmacies, and pharmacists will cooperate with all other medical personnel to assist the wounded and injured and regular in groups according to their presence in each area of Sudan.

December 29, 2018

An American health worker who has been caring for patients infected with Ebola in the Democratic Republic of the Congo was flown back to the United States after having what is described as “a possible exposure” to an Ebola patient.

The person was flown by charter flight to Omaha and admitted for observation to Nebraska Medical Center. The center has a special containment unit in which it can care for people with dangerous infectious diseases.

The person isn’t displaying symptoms of Ebola, the center said in a statement. But the medical evacuation ensures quick access to specialized care if symptoms develop.

“This person may have been exposed to the virus but is not ill and is not contagious,” Dr. Ted Cieslak, an infectious diseases specialist, said in the statement from Nebraska Medicine.

The hospital has access to experimental Ebola therapies that it could use to treat the person if he or she becomes ill, spokesman Taylor Wilson told STAT.

The health worker’s identity has not been disclosed, nor has information been released about how he or she was possibly exposed to the deadly virus, and when.

The incubation period for Ebola is two to 21 days, with most people who develop the disease showing symptoms within eight to 10 days. The statement from Nebraska Medical said monitoring could last up to two weeks, which suggests several days may have passed since the exposure event.

The statement also did not say whether the individual had been vaccinated with the experimental Ebola vaccine that Merck is testing, either before beginning work in DRC or after the exposure event. So far in this outbreak, 54 health workers have been infected and 18 have died.

The statement said the individual had asked for privacy and the request would be honored.

The individual is likely someone working with one of the medical charities caring for Ebola patients in the outbreak zone. U.S. government employees have been barred from working on the ground in this outbreak, because of security concerns. Consequently, no one from the Centers for Disease Control and Prevention or the United States Agency for International Development — USAID — have been working in the outbreak zone in northeastern Congo since late August.